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Quality Matters: The Graying of Emergency Medicine

Welch, Shari MD; Sanson, Tracy MD

Emergency Medicine News: July 2011 - Volume 33 - Issue 7 - p 8
doi: 10.1097/01.EEM.0000399752.03277.ff
Quality Matters

As the first wave of career emergency physicians charges headlong into retirement, physician groups are struggling with how to manage the aging workforce in our particularly vigorous specialty. With a physician shortage already stressing the workforce, putting older doctors out to pasture is not a viable strategy.

Physician groups in emergency medicine are not known for their long-term planning, and unlike the business world, few pay attention to succession planning and seniority policies. Few groups have a vision for what the practice of emergency medicine should look like in the various phases of a physician's life cycle. We are a specialty in search of flexibility and creative re-engineering of our work environment. Progressive scheduling models and employee motivation packages are on the radar of physician leaders and managers.

Rewarding longevity and loyalty to the team is common in the contemporary workplace. Often professionals in business, law, and engineering have tiers of seniority with pay and benefits commensurate with experience. In emergency medicine, the monetary rewards, vacation, and benefits are level almost immediately. The only way to acknowledge loyalty and longevity is through small concessions in the schedule, with most physician groups exempting physicians from night work at a certain age.

Bruce Janiak, MD, the first-ever emergency medicine resident in the United States, has reached retirement age at the Medical College of Georgia. Though they make few concessions to senior doctors there, they have added financial incentives to weekend, holiday, and other undesirable shifts so younger physicians often choose to work for the remuneration. According to the American Medical Association, the average medical student graduates with $155,000 in debt. ( Younger physicians trying to purchase homes and pay off education debts often find these financial incentives help them achieve personal goals, and there is a sense of fairness in them. Although this strategy has long served as a primary method to adapt the schedule for variations in physician age and stamina, it may not prove an enduring strategy for the future.

A recent survey of U.S. physicians conducted by the Association of American Medical Colleges (AAMC) and the American Medical Association found that young doctors of both genders view “quality of life” as essential, and are willing to risk career advancement to get it. ( Another study found that Generation X physicians (born 1962-1981) rank compensation below other attributes they look for in a job. More significant to them: recognition, praise, opportunities to learn, time spent with mentors developing marketable skills, and fun at work. (Video: Studies like these and real-life experiences with scheduling lead us to beg the question: What is a full-time equivalent in today's marketplace?

Multigenerational groups have members with different mindsets about work. When some older emergency physicians started their careers in emergency medicine, some groups were “closed to partners,” and some expected a financial buy-in. It was not unusual to borrow money to buy into a group practice. It was expected that there would be certain prices to pay in terms of “sweat equity,” but over time, the work world would improve. Millennial physicians are different. They expect almost immediate parity, and according to new data, they are more mobile and less committed to their groups, though, according to EMN columnist Barbara Katz, they are committed to a location. (Millennial physician five-part series, November 2010-March 2011;

They are not willing to work the hours of the generations that preceded us, and they place a premium on lifestyle. Emergency physician contracts in the 1980s required close to 2,000 hours of clinical work a year. There are groups that now only require 1,300 hundred clinical hours per year or less. We really approach the practice of emergency medicine from wildly different perspectives and with vastly different histories. It is worth acknowledging those differences as we move forward and try to craft group practice policies that are acceptable to all.

There is no denying that physician performance declines in later years or that cognitive and motor skills deteriorate with age. Most hospital bylaws stipulate a maximum age for surgeons to perform surgery and to maintain privileges. (Pilots in the United States face mandatory retirement from flying at age 65.) Many organizations are developing policies for monitoring the clinical performance of physicians after 70, and aging physician policy and procedure documents are cropping up on medical staff meeting agendas. One thing is certain: We do want the older physicians to work as long as possible. They add elasticity to the schedule, and are often available to work when physicians with younger families desperately need off. They provide stable connections to the community that often protect the local group when large management groups come calling on the C-suites.

Having a physician workforce with varied histories, capabilities, interests, and skills can be positive for a group. One intriguing example of this was offered from an attendee at a recent ED operations management course. The physician was over 65, and said older physicians are a great resource, particularly for physician-in-triage models. “If there is one thing guys like me have honed, it is the ability to recognize sick/not sick,” he said. “Sometimes I think I am too old and tired to man the back of the ED. But I am really good at that blink response in triage. The younger guys want to be in the back in the middle of the action. I am happy to make hundreds of front-end decisions in triage!”

There is another area where older physicians can make a contribution, and as Greg Henry, MD, has noted, younger physicians have less interest in administrative and management work, while more senior physicians often enjoy this type of work. Groups would do well to take advantage of such interest and expertise.

The point is this: The physician workforce in emergency medicine, just like the physician workforce at large, is aging, and with this comes changes in our collective practice. Baby boomers worked longer hours than their younger physician cohorts of today, and their departure from the workforce will greatly affect the practice of emergency medicine.

Skills, stamina, and capability will change over time. Physician groups need to begin exploring ways to continue to utilize these physicians in emergency medicine while acknowledging that we will all march through these professional phases. Our success will be predicated on respect for all. While we may have differences, quite a bit of common ground exists given our shared patient care values and personality traits.

If we are to engage all physicians and improve relationships, our answer must be flexibility all around, such as job sharing, part-time work, split shifts, and flexible schedules. Crafting policies that make use of the special expertise and limitations of older physicians while understanding the values and needs of their younger colleagues is where it all has to start.

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